Health Service Focus

Room for improvement in GP receptionist stroke referral

A new study has looked at the important role GP receptionists play in directing stroke patients towards timely, emergency care. However, there is room for improvement, as report author Dr James Sheppard, a Medical Research Council Research Fellow from the Nuffield Department of Primary Care Health Sciences at the University of Oxford, explains.
Providing GP receptionists with specialist training in identifying the less-common symptoms of stroke could help ensure patients are triaged correctly to emergency medical services, a new study suggests.

Conducted by the universities of Oxford and Birmingham, the RECEPTS study, which used ‘mystery shopper’ telephone calls from researchers posing as patients with stroke symptoms, revealed that about one-third of calls to GP practices were not recognised as emergencies.

RECEPTS, designed to understand how GP reception staff recognise and respond to patients with stroke symptoms, involved 52 family practices across the West Midlands, using questionnaires, focus groups and ‘mystery shopper’ telephone calls.

Calls with fewer or no symptoms used in the Act FAST campaign – Has their face fallen? Can they raise both arms? Is their speech slurred? – were less likely to be immediately referred than calls with all three FAST symptoms.

Dr James Sheppard, a Medical Research Council Research Fellow from the Nuffield Department of Primary Care Health Sciences at the University of Oxford, and an author of the report, told NHE: “We were quite impressed with how receptionists did, and we didn’t want to be seen as knocking GP receptionists and practices for not doing their job properly. I think what they do it is quite difficult, as it is hard to recognise stroke, even if you are an expert stroke physician.”

The study was done because previous work revealed that the GP is the first point of contact for between 22% and 56% of patients with acute stroke or transient ischaemic attack, but only 55% to 71% of these are correctly referred on to the emergency services for immediate care.

“And we found that those who called their GP were a lot less likely to get to hospital in time to receive thrombolysis treatment, the clot-busting drugs which often lead to better outcomes in stroke,” said Dr Sheppard. “We wanted to understand that dynamic better, which is why we set up the study.”

Early diagnosis and time-dependant treatment in a specialist hospital unit can improve a patient’s chances of survival and their quality of life post-stroke.

Each practice received 10 calls from actors mimicking between one and three symptoms of stroke, and the receptionist was not aware the situation was simulated until the end of the call.

Almost all the receptionists (96%) were able to name at least one stroke symptom from the FAST campaign, but 40% reported one or more incorrect symptoms. And difficult to recognise calls – where symptoms were not obvious – were 85% less likely to be immediately referred than easy to recognise calls.

Only 14% of receptionists in the current study reported receiving training related to stroke. And in the UK there are no national educational structures for GP receptionists.

However, Dr Sheppard said that this study has helped raise awareness, and “actually that training of receptionists would be beneficial if training and resources were available”.

The report suggests that GPs and policymakers should consider the development of interventions to improve recognition of the less common symptoms of stroke, to ensure that these patients are not delayed in accessing time-dependent treatment in secondary care.

“Training sessions and e-learning modules could go some way to fulfilling this need,” NHE was told.
Sheppard added that his colleagues in Birmingham are now carrying out a smaller study in the West Midlands having set up a training resource, which can be delivered as an online training course or people can go into practices and deliver it.

“This includes information on the typical FAST symptoms, but also information about why it is important,” he said. “Certainly with the public FAST campaign, which is about recognising symptoms and calling 999 as soon as possible, it doesn’t explain why it is important. This is because it is only in a 90 second ad-spot or on a poster, so you can’t go into the detail.

“I think it is sometimes helpful to realise that, actually, the reason you need to get to hospital quickly is because the treatment is effective, but it is only effective 4.5 hours after symptoms have begun. Understanding that can help you realise and better understand the urgency of the situation.”

He added that it will be interesting to see how the evaluation of the new training package in Birmingham unfolds. “The study we did was setting the scene rather than saying that training would work,” said Dr Sheppard. “I think you would need to show that it works in a controlled research setting, and once you’ve done that you can make firmer recommendations – especially as training can be expensive and you need to justify whether it would lead to improved patient outcomes.”

FOR MORE INFORMATION
W: www.stroke.org/understand-stroke/recognizing-stroke/act-fast